Predicting the need for tenotomy in the Ponseti method for correction of clubfeet

A single-center, single-blinded, randomized, parallel-group, non-inferiority trial to compare the efficacy of a 22-gauge needle versus a 15 blade to perform an Achilles tendon tenotomy in 244 clubfeet-study protocol

BACKGROUND

Achilles tendon tenotomy is an integral part of the Ponseti method, aimed at correcting residual equinus and lack of dorsiflexion after correction of the adductus deformity in clubfoot. Percutaneous tenotomy using a number 15 scalpel blade is considered the gold standard, resulting in excellent results with minimal complications. The use of a large-bore needle to perform Achilles tendon tenotomies has been described in literature, but a large-scale randomized controlled trial is currently lacking. In this trial, we aim to show the non-inferiority of the needle tenotomy technique compared to the gold standard blade tenotomy technique.

METHODS

We will randomize 244 feet into group A: needle tenotomy or group B: blade tenotomy. Randomization will be done using a block randomization with random block sizes and applying a 1:1 allocation to achieve an intervention and control group of the exact same size. Children will be evaluated at 3 weeks and 3 months post-tenotomy for primary and secondary clinical outcomes. The primary clinical outcome will be the range of dorsiflexion obtained the secondary clinical outcomes will be frequency of minor and major complications and Pirani score. The non-inferiority margin was set at 4°, and thus, the null hypothesis of inferiority of the needle technique will be rejected if the mean difference between both techniques is less than 4°. The statistical analysis will use a multi-level mixed effects linear regression model for the primary outcomes and a multi-level mixed effects logistic regression model for the secondary clinical outcomes. The physician performing the evaluations post-tenotomy will be the only one blinded to group allocation.

TRIAL REGISTRATION

This trial was registered prospectively with ClinicalTrials.gov registration number: NCT04897100 on 21 May 2021.

Semirigid Fiberglass Casting for the Early Management of Clubfoot: A Single-Center Experience

Background

Semirigid fiberglass (SRF) is an alternative material to plaster of Paris (POP) for idiopathic clubfoot casting in the Ponseti method. The purpose of this study was to evaluate early clinical outcomes in a series of idiopathic clubfoot patients treated with SRF at a single institution and to compare these findings to historical norms with POP casting present in the literature.

Methods

A series of idiopathic clubfoot patients managed exclusively with SRF in the Ponseti method was identified. Treatment efficacy was evaluated by number of casts, change in Pirani score, frequency of treatment-related complications, and frequency of surgery other than tenotomy. A comprehensive literature review was used for comparative historical norms.

Results

The study included 34 feet in 26 patients. Pirani score was 4.7±1.3 at presentation and 1.9±1.4 at the end of casting, representing a score change of 2.8±1.3 with SRF. Initial correction was obtained with 6.9±1.4 casts. Treatment-related complications occurred in six treated feet (17.6%) including 13 cast slippages in five feet and one cast-related thigh abrasion. A total of 25 (73.5%) feet underwent tenotomy. Two feet required an additional surgical procedure.

Conclusion

Clubfoot patients treated with SRF demonstrated acceptable deformity correction following Ponseti-style casting. The quantitative clinical outcomes evaluated appeared similar to norms using POP present in the literature. The findings of this study support SRF as a viable alternative to plaster casting for clubfoot correction utilizing the Ponseti method. As such, further investigation for rigorous comparative assessment is warranted.

A modification of the Ponseti method for clubfoot management: a prospective comparative study

PURPOSE

We aimed to compare our parent-based exercise programem's efficacy with the foot abduction brace (FAB) Ponseti manipulation as a retention programme.

METHODS

We conducted this prospective multicentre cohort study between August 2009 and November 2019. The included children were allocated into one of two groups according to the retention protocol. The Pirani and Laaveg-Ponseti scores were used to assess the feet clinically and functionally. Radiological assessment was performed using standing anteroposterior and lateral radiographs of the feet. We assessed the parents' satisfaction and adherence to the retention method. SPSS version 25 was used for the statistical analysis.

RESULTS

A total of 1265 feet in 973 children were included. Group A included 637 feet managed with FAB, while group B included 628 feet managed with our retention programme. All patients were followed up to the age of four years. At the final follow-up, Pirani scores in group A participants were excellent, good and poor in 515, 90, and 32 feet, respectivel, while in group B the scores were excellent, good and poor in 471, 110 and 44 feet, respectively. The mean total score of Laaveg-Ponseti was 87.81 (sd 19.82) in group A and 90.55 (sd 20.71) in group B (p = 0.02). Group B participants showed higher satisfaction with the treatment method (p = 0.011) and more adherence to the treatment (p = 0.013).

CONCLUSION

The deformity's recurrence related to the brace's non-compliance in the Ponseti method might be reduced by substituting the brace with our home-based daily stretching exercises.

LEVEL OF EVIDENCE

II.

Influence of Beginning Time of Casting for Clubfoot Treatment by Ponseti Method in Different Age Group Infants: A Retrospective Study

BACKGROUND

The clubfoot is one of the commonly found congenital deformities in newborn. The Ponseti method is the most effective nonoperative clubfoot management method. It is based on understanding of pathoanatomy of clubfoot. For classifying severity of clubfoot, Pirani score is used. The number of cast required for clubfoot correction is dependent on its initial Pirani score. This study aimed on how the number of cast for correction of clubfoot deformity depends on starting time of casting and pretreatment Pirani score.

MATERIALS AND METHODS

This study comprises of 200 patients with 297 affected foot nonoperatively managed with Ponseti technique of casting. We measured initial and final Pirani scores of patients with different age groups.

RESULTS

We found that initial severity was less in 0-1 month age group children but mean casting number was more while initial severity was more in 1-2 month age group, the mean number of casting was less. Tenotomy requirement was also less in 1-2 month age group.

CONCLUSION

We concluded that casting according to the Ponseti method should be started in 1-2 months age group which shows better results than the other age groups in clubfoot.

Early management of clubfoot by the Ponseti method with complete percutaneous tenotomy of tendoachillis

Background and Objective:

As a highly common congenital deformity which can lead to serious walking problems, clubfoot has long been treated using the Ponseti method which is usually carried out without complete percutaneous tenotomy of tendoachillis. The present study was aimed at investigating the effects of early management of clubfoot by the Ponseti method with a complete percutaneous tenotomy of tendoachillis in Erbil Teaching Hospital located in Erbil, the Kurdistan Region of Iraq.

Methods:

Thirty neonates <3 months of age who had congenital idiopathic clubfoot were randomly selected. They were treated by the Ponseti method. For this purpose, successive casts were applied for them for 3 weeks, with changing the casts on a weekly basis. For those who did not respond to the first 3 weeks of casting, the classical Ponseti method was utilized along with complete percutaneous tenotomy of tendoachillis based on the theory of stem cell regeneration. Then, the casting was performed for 6 weeks, followed by foot abduction brace and maintained using a foot abduction brace (Dennis brown splint) until school age 5-6 years. The collected data were analyzed using the χ² test through SPSS 22.0.

Results:

The results of the present study indicated that the most prevalent type of clubfoot was the unilateral type with 73.3% prevalence rate. Treating the newborns with clubfoot by the Ponseti method along with complete percutaneous tenotomy of tendoachillis led to good results in 86.7% of the cases, medium in 3 cases (10%), and poor only in 1 case (3.3%).

Conclusion:

Ponseti method along with complete percutaneous tenotomy of tendoachillis was proved to be an efficient method to treat clubfoot during the first few weeks of life.

ARE SCORING SYSTEMS USEFUL FOR PREDICTING RESULTS OF TREATMENT FOR CLUBFOOT USING THE PONSETI METHOD?

Objective:

The aim of this study was to verify whether the Pirani and Dimeglio clinical scoring systems could predict results of Ponseti therapy.

Methods:

Forty-seven patients with clubfoot deformities treated with the Ponseti method were enrolled in the study. Clinical evaluation with the Pirani and Dimeglio scoring systems was performed before the treatment and after the second cast fixation. The number of fixations, necessity for achillotomy, and recurrence of the deformity were determined as parameters of the therapy results. The patients were divided into three groups according to the severity of their deformities, and the groups were compared with one another.

Results:

Clubfoot correction required an average of 6.8 casts. Five patients developed a recurrence. Comparing the therapy outcomes among the groups, we found statistically significant differences in the Pirani classification after the second fixation (the number of casts [p =.003] and necessity to perform an achillotomy [p =.014]) and in the Dimeglio scores before therapy (number of casts [p =.034]) and after the second fixation (number of relapses [p =.032]).

Conclusion:

Although clinical scoring systems showed some dependence on the parameters of treatment outcomes, their predictive function can be used in only a limited way. Level of evidence II, Prospective comparative study.

Percutaneous heel cord release for clubfoot: a retrospective, multicentre cost analysis

PURPOSE

The Ponseti method of treatment is the standard of care for idiopathic clubfoot. Following serial casting, percutaneous tendo-Achilles tenotomy (TAT) is performed to correct residual equinus. This procedure can be performed in either the outpatient clinic or the operating room. The purpose of this study was to evaluate the expense of this procedure by examining hospital charges in both settings.

METHODS

We retrospectively reviewed charts of 382 idiopathic clubfoot patients with a mean age of 2.4 months (0.6 to 26.6) treated with the Ponseti method at three institutions. Patients were divided into three groups depending on the setting for the TAT procedure: 140 patients in the outpatient clinic (CL), 219 in the operating room with discharge following the procedure (OR) and 23 in the operating room with admission to hospital for observation (OR+). Medical records were reviewed to analyze age, deformity, perioperative complications and specific time spent in each setting. Hospital charges for all three groups were standardized to one institution's charge structure.

RESULTS

Charges among the three groups undergoing TAT (CL, OR, OR+) were found to be significantly different ($3840.60 versus $7962.30 versus $9110.00, respectively; p ≤ 0.001), and remained significant when separating unilateral and bilateral deformities (p < 0.001). There were nine total perioperative complications (six returns to the ER and three unexpected admissions to the hospital): five (2.3%) in the OR group, four (17.4%) in the OR+ group and none in the CL group. The OR+ group statistically had a higher rate of complications compared with the other two groups (p = 0.006). The total event time of the CL group was significantly shorter compared with the OR and OR+ groups (129.1, 171.7 and 1571.6 minutes respectively; p < 0.001).

CONCLUSION

Hospital charges and total event time were significantly less when percutaneous TAT was performed in the outpatient clinic compared with the operating room. In addition, performing the procedure in clinic was associated with the lowest rate of complications.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Can the Pirani Score Predict the Number of Casts and the Need for Tenotomy in the Management of Clubfoot by the Ponseti Method?

Introduction: We assessed the role of the Pirani score in determining the number of casts and its ability to suggest requirement for tenotomy in the management of clubfoot by the Ponseti method.

Materials and Methods: Prospective analysis of 66 (110 feet) cases of idiopathic clubfoot up to one year of age was done. Exclusion criteria included children more than one year of age at the start of treatment, non-idiopathic cases and previously treated or operated cases.

Results: The initial Pirani score was (5.5±0.7) for the tenotomy group and the initial Pirani score was (3.3±1.6) for the non-tenotomy group. There was a significant difference between the initial Pirani score for the tenotomy and the non-tenotomy group with t= -7.9, df= 64 p<0.0001. The tenotomy group had a significantly higher number of casts (four to seven) compared to non-tenotomy group (two to five) t=-10.4, df=64, p<0.0001. Spearman’s rank correlation coefficient was significant and confirmed positive correlation between the initial Pirani score and the number of casts required to correct the deformity (r = 0.931, p<0.0001).

Conclusion: Initial high Pirani score suggests the need for greater number of casts to achieve correction and probable need for tenotomy. The number of casts required in achieving complete correction increases with increase in the initial Pirani score. The initial high hindfoot score (2.5-3) signifies the probable need of a minor surgical intervention of percutaneous tendoachilles tenotomy. Based on the initial Pirani score, parents can be informed about the probable duration of treatment and the need for tenotomy.

Comparison of Dimeglio and Pirani score in predicting number of casts and need for tenotomy in clubfoot correction using the Ponseti method

PURPOSE

The Dimeglio and the Pirani scores are largely used to rate clubfoot at presentation and monitor correction. To date, the accuracy of these scores in predicting appropriate treatment is controversial. The aim of this study was to investigate the accuracy of Dimeglio and Pirani scores in predicting the number of casts and the need for tenotomy in clubfoot correction using the Ponseti method.

METHODS

Ninety-one consecutive feet (54 patients; mean age at presentation: 28 ± 15 days) undergoing clubfoot correction using the Ponseti method were prospectively followed from first casting to correction. All feet were scored according to the Dimeglio and Pirani score. The relationships between the two scores, the number of casts and the need for tenotomy were analysed.

RESULTS

Initial correction was achieved in all feet. Both Dimeglio (r = .73; p value < .0005) and Pirani scores (r = .56; p value < .000) showed good association with the number of casts. Multiple linear regression showed a high collinearity of the two scores but a more significant contribution of the Dimeglio score. Among subcomponents, hindfoot score, midfoot score, varus and muscular abnormality were independent predictors of the number of casts. Both Dimeglio and Pirani scores were significantly associated with the need for tenotomy (p value = .0000), and odds ratios and cut-off points were calculated. The receiving operator curve (ROC) analysis showed slightly better performance of the Dimeglio in comparison with the Pirani score in predicting the need for tenotomy, but the difference between the two areas under the curve (AUC) was not significant (p = .48).

CONCLUSIONS

A quite accurate prediction of the number of casts and the need for tenotomy can be performed in most cases. The Dimeglio score showed slightly better accuracy in predicting both steps of Ponseti treatment.

A prospective cohort study on comparison of early outcome of classical Ponseti and modified Ponseti post tenotomy in clubfoot management

Introduction

Ponseti method has become the main treatment modality for the management of clubfoot producing good long-term results. However, variation in cast application post tenotomy has not been evaluated.

Methods

A prospective cohort study involving 40 patients with 67 clubfeet were randomized into two groups: 32 above knee cast (AKC) and 35 below knee cast (BKC) after percutaneous tenotomy. All had foot abduction brace after post tenotomy cast. The median age was 21 weeks (range: 1–104 weeks) and 1.9:1 male/female ratio. 27 (67.5%) patients had bilateral clubfoot and unilateral in 13 (32.5%). Patients were followed-up for 6 months with documentation of the Pirani Score and the cost of treatment.

Results

No significant difference between AKC and BKC mean Pirani score before treatment (p = 0.550) and after treatment (p = 0.702). However, mean Pirani score at 6 months was significantly different (p = 0.038). Overall mean number of casting was 6.4 in AKC group and 4.7 in BKC group (p = 0.003). There was recurrence in 2 feet before completion of treatment (6.3%) among AKC and none among BKC group. However, there was no recurrence at 6 months after treatment in both groups. The mean cost for AKC and BKC were ₦10,427.34 (52.33 US dollars) and ₦7021.54 (35.24 US dollars) respectively (p = 0.002).

Conclusion

Early results of below knee cast after tenotomy were comparable to the classical above knee cast after tenotomy in Ponseti treatment protocol for clubfoot. There was also reduction in cost of treatment in the modified Ponseti compared to the classical Ponseti. Long-term result will be desirable.

•

A prospective study of idiopathic congenital talipes equinovarus at a University Teaching Hospitals Complex. Forty patients were recruited, all below the age of two years but with median age of 12 weeks and male to female ratio of 1.9:1. Twenty seven of the patients had bilateral clubfoot while thirteen had unilateral clubfoot amounting to 67 clubfeet considered.

•

All the patients were evaluated at the Ponseti clinic and treatment commenced for them based on Ponseti treatment protocol. They all had serial manipulation and above knee casting to correct the cavus, adduction, varus deformities in that order. The last deformity to be corrected was equinus which required percutaneous Achilles tenotomy before above knee cast for three weeks.

•

The patients at this stage were randomized into two group: above knee cast after tenotomy which is the control group that followed the classical Ponseti treatment protocol and below knee cast after tenotomy which was the study group. The parameters considered in them were the Pirani score before, after and at 6months after treatment and the cost differentials. Thirty two feet were in the control group while thirty five feet were in the study group. Early result showed that below knee cast after tenotomy was comparable to the classical Ponseti treatment and cost difference was significant.

Interobserver variability in Pirani clubfoot severity scoring system between the orthopedic surgeons

BACKGROUND

Congenital talipes equinovarus (clubfoot) is one of the most common congenital pediatric orthopedic foot deformity, which varies in severity and clinical course. Assessment of severity of the club foot deformity is essential to assess the initial severity of deformity, to monitor the progress of treatment, to prognosticate, and to identify early relapse. Pirani's scoring system is most acceptable and popular for club foot deformity assessment because it is simple, quick, cost effective, and easy. Since the scoring system is subjective in nature it has inter- and intra-observer variability, it is widely used. Hence, the interobserver variability between orthopedic surgeons in assessing the club foot severity by Pirani scoring system.

MATERIALS AND METHODS

We assessed the interobserver variability between five orthopedic surgeons of comparable skills, in assessing the club foot severity by Pirani scoring system in 80 feet of 60 children (20 bilateral and 40 unilateral) with club foot deformity. All the five different orthopedic surgeons were familiar with Pirani clubfoot severity scoring and Ponseti cast manipulation, as they had already worked in CTEV clinics for at least 2 months. Each of them independently scored, each foot as per the Pirani clubfoot scoring system and recorded total score (TS), Midfoot score (MFS), Hind foot score (HFS), posterior crease (PC), emptiness of heel (EH), rigidity of equnius (RE), medial crease (MC), curvature of lateral border (CLB), and lateral head of talus (LHT). Interobserver variability was calculated using kappa statistic for each of these signs and was judged as poor (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), or almost perfect (0.81-1.00).

RESULTS

The mean age was 137 days (range 21-335) days. The mean Pirani score was 3.86. We found the overall consistency to be substantial for overall score (total score kappa - 0.71) and also for midfoot (0.68) and hindfoot (0.66) separately. The consistency was least for the emptiness of heel (kappa - 0.39), and best for rigidity of equnius (kappa - 0.68) and rest of the parameters were moderate (kappa between 0.40 and 0.60).

CONCLUSION

The Pirani scoring system had got substantial reliability in assessing the clubfoot deformity even when the reliability test was extended to five different orthopedic surgeons simultaneously.

Treatment of persistent forefoot adduction during ponseti method in treatment of idiopathic talipes equinovarus by minimal soft release

INTRODUCTION

Abductor hallucies tenotomy sometimes necessary in treatment of clubfoot.

MATERIAL AND METHODS

Thirty children (45 feet) of one day old up to six months presented with idiopathic clubfoot. Patients were treated using the technique of Ponseti combined by abductor hallucies tenotomy after serial casting.

RESULTS

At a mean follow up period of 16.7 months, 43/45 feet were good (95%), 2/45 feet were bad (5%). The mean Pirani score at the final follow up was 1.05.

CONCLUSION

Abductor hallucies tenotomy shortens the duration of casts, decrease the cost and risk of leg atrophy.

Manipulation and brace fixing for the treatment of congenital clubfoot in newborns and infants

Background

As one of the most common congenital deformities in children, clubfoot has long been a challenge for orthopedic surgeons. This paper describes the experience of our team with manipulation and above-the-knee brace fixation without percutaneous Achilles tenotomy for the treatment of clubfoot in newborns and infants.

Methods

In the orthopedic department of our hospital, 32 infants and newborns (56 feet) with congenital clubfoot underwent manipulation and above-the-knee brace fixation between 2008 and 2012. External rotation brace was used for 1–4 years during the night after deformity correction. Prospective follow-up for a mean duration of 29 months (range, 12–48 months) was carried out. The efficacy of the treatment was assessed by Pirani’s scoring system before and after treatment.

Results

Fifty-two feet achieved a normal appearance within 3 to 6 months (average, 4.2 months) after treatment. Two patients had skin pressure sores due to improper brace care, but these healed with no scarring after timely treatment. The mean Pirani score 1 year after treatment was 0.21 ± 0.09, whereas it was 4.93 ± 1.02 before treatment (p = 0.0078). No patient required treatment with percutaneous Achilles tenotomy.

Conclusion

The manipulation and brace fixation used in this study offer an effective method for correcting clubfoot deformity in newborns and infants. This treatment can be an alternative choice to percutaneous Achilles tenotomy.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-363) contains supplementary material, which is available to authorized users.

Does initial Pirani score and age influence number of Ponseti casts in children?

PURPOSE

The prediction of number of casts in the Ponseti method has always remained a subject of interest. We investigated the correlation of the number of casts before tenotomy with the age and initial Pirani score in Ponseti treatment of club foot.

METHODS

Inclusion criteria were idiopathic clubfeet corrected by Ponseti method requiring tenotomy for equinus correction in children up to ten years of age. Defaulters (noncompliance with serial casting schedule), children with postural, non idiopathic, previously surgically treated, recurrent clubfoot and clubfoot not requiring tenotomy were not included in this study. Further, children who did not require tenotomy were also excluded. ANOVA regression analysis was used for finding correlation between initial Pirani score, age in months and number of corrective casts prior to tenotomy.

RESULTS

There were a total of 297 children (442 feet) in the study. The average age of the child at presentation was 10.3 months and the average initial Pirani score was 4.8. The average number of corrective casts was seven per child (range, two to18). The regression analysis showed both Pirani and age had positive correlation with number of casts, although weak (r2 = 0.05-0.20). The initial Pirani scoring correlated ten times more than age (in months) to the number of casts.

CONCLUSION

The number of casts for correction in idiopathic clubfoot, although variable, is influenced by both initial Pirani score and age.

Treatment of idiopathic congenital clubfoot using the Ponseti method: ten years of experience

Objective

To evaluate outcomes of 229 idiopathic clubfeet (ICF) treated using the Ponseti method, from 2001 to 2011, comparing two groups with different follow-ups.

Method

155 patients (229 ICF) were treated separated in two groups: Group I: 72 patients (109 ICF – 47.6%) with a follow up of 62 to 128 months (mean of 85). Group II: 83 patients (120 ICF – 52.4%) with a follow up of 4 to 57 months (mean of 33.5). We have considered satisfactory outcomes for cases which correction of all deformed components, without surgery.

Results

Mean age for the initial assessment was 5.4 months in Group I and 3.2 in Group II. Satisfactory outcomes were obtained in 85.4% in Group I and 97.5% in Group II. Mean cast placements were 9.5 in Group I and 7 in Group II. 67% were submitted to percutaneous Achilles tenotomy in Group I and 65% in Group II. Deformity relapses, when using abducted braces, occurred in 41 (37.6%) feet from Group I; 11 were treated surgically. In Group II, 17 feet relapsed (14.1%); three of them were submitted to surgery.

Conclusion

The method was successful in both groups, in low number of complications. The results were statistically superior in Group II when deformity correction, cast placements, relapses and surgery indication.

Predictive factors for residual equinovarus deformity following Ponseti treatment and percutaneous Achilles tenotomy for idiopathic clubfoot: a retrospective review of 50 cases followed for median 2 years

BACKGROUND AND PURPOSE

There is no consensus on how to predict residual equinovarus deformities after application of the Ponseti method. We assessed the prognostic value of clinical scoring systems, and also radiographic parameters that can be measured just before percutaneous Achilles tenotomy (PAT).

METHOD

We reviewed 50 cases of clubfoot in 35 patients who were treated using the Ponseti method, including PAT, to analyze the factors that are predictive of residual equinovarus deformities. Mean age at the time of PAT was 2.4 (1.4-3.5) months, and the mean follow-up period was 23 (9-61) months. We divided these cases into 2 groups according to the need for further surgery to treat the residual deformities.

RESULTS

40 feet with satisfactory results were included in group 1, whereas the remaining 10 feet that required further surgery for unsatisfactory residual deformities were included in group 2. We compared the initial Dimeglio and Pirani scores obtained before the first Ponseti casting, follow-up Pirani scores, and radiographic parameters determined just before PAT between these 2 groups. There was no statistically significant difference between the groups in terms of the initial Dimeglio and Pirani scores, although the follow-up Pirani scores and lateral tibiocalcaneal angle were higher and the lateral talocalcaneal angle was lower in group 2 at the time of PAT.

INTERPRETATION

We conclude that the Pirani score, lateral tibiocalcaneal angle, and talocalcaneal angle, when assessed immediately before PAT, might be predictive factors for residual equinovarus deformity following Ponseti treatment for severe idiopathic clubfoot.

Ultrasonographic observation of the healing process in the gap after a Ponseti-type Achilles tenotomy for idiopathic congenital clubfoot at two-year follow-up

BACKGROUND

Ponseti management usually requires Achilles tenotomy during the final stage of serial casting. However, we lack a good understanding of the sequential tendon healing process after tenotomy in the Ponseti bracing protocol. The purpose of this study was to clarify the ultrasonographic process of tendon healing in the gap for up to two years after Ponseti-type Achilles tenotomy in patients with clubfeet.

METHODS

We conducted an ultrasonographic study to clarify the sequential changes in gap healing for up to two years after tenotomy. The subjects were 23 patients with 33 clubfeet. Achilles tenotomy was performed at mean 10.4 (8-16) weeks after birth. Dynamic and static ultrasonography was performed before tenotomy and at 1, 2, 3, 4, 6, 8, and 12 weeks as well as at 4, 6, 12, 18, and 24 months after tenotomy.

RESULTS

Continuity and gliding were noted within four weeks. The united portion continued to thicken for up to three months after tenotomy. Starting from the fourth month, the healed portion began to lose its thickness, and this process continued into the sixth month. At one year, the thickness of the tendon did not differ much from that of the tendon on the opposing foot. In cases where patients had clubfoot on both feet and underwent simultaneous tenotomies, measurement of the tendons could not be accurately compared. At two years after tenotomy, slight irregularity of the internal structure persisted when compared with the unaffected foot. In addition, clinical and X-ray findings were evaluated simultaneously, and no recurrence was confirmed.

CONCLUSIONS

To our knowledge, our results are the first to describe the process of gap healing in the tendon after tenotomy up to and beyond two years, as recommended in the Ponseti bracing protocol. Level of evidence IV.

Classification of relapse pattern in clubfoot treated with Ponseti technique

BACKGROUND

Relapse of clubfoot deformity following correction by Ponseti technique is not uncommon. The relapsed feet progress from flexible to rigid if left untreated and can become as severe as the initial deformity. No definitive classification exists to assess a relapsed clubfoot. Some authors have used the Pirani score to rate the relapse while others have used descriptive terms. The purpose of this study is to analyze the relapse pattern in clubfeet that have undergone treatment with the Ponseti method and propose a simple classification for relapsed clubfeet.

MATERIALS AND METHODS

Ninety-one children (164 feet) with idiopathic clubfeet who underwent treatment with Ponseti technique presented with relapse of the deformity. There were 68 boys and 23 girls. Mean age at presentation for casting was 10.71 days (range 7-22 days). Seventy three children (146 feet, 80%) had bilateral involvement and 18 (20%) had unilateral clubfeet. The mean Pirani Score was 5.6 and 5.5 in bilateral and unilateral groups respectively. Percutaneous heel cord tenotomy was done in 65 children (130 feet, 89%) in the bilateral group and in 12 children (66%) with unilateral clubfoot.

RESULTS

Five relapse patterns were identified at a mean followup of 4.5 years (range 3-5 years) which forms the basis of this study. These relapse patterns were classified as: Grade IA: decrease in ankle dorsiflexion from15 degrees to neutral, Grade IB: dynamic forefoot adduction or supination, Grade IIA - rigid equinus, Grade IIB - rigid adduction of forefoot/midfoot complex and Grade III: combination of two or more deformities: Fixed equinus, varus and forefoot adduction. In the bilateral group, 21 children (38 feet, 28%) had Grade IA relapse. Twenty four children (46 feet, 34%) had dynamic intoeing (Grade IB) on walking. Thirteen children (22 feet, 16%) had true ankle equinus of varying degress (Grade IIA); eight children (13 feet, 9.7%) had fixed adduction deformity of the forefoot (Grade IIB) and seven children (14 feet, 10.7%) had two or more fixed deformities. In the unilateral group seven cases (38%) had reduced dorsiflexion (Grade IA), six (33%) had dynamic adduction (Grade IB), two (11%) had fixed equinus and adduction respectively (Grade IIA and IIB) and one (5%) child had fixed equinus and adduction deformity (Grade III). The relapses were treated by full time splint application, re-casting, tibialis anterior transfer, posterior release, corrective lateral closing wedge osteotomy and a comprehensive subtalar release. Splint compliance was compromised in both groups.

CONCLUSION

Relapse pattern in clubfeet can be broadly classified into three distinct subsets. Early identification of relapses and early intervention will prevent major soft tissue surgery. A universal language of relapse pattern will allow comparison of results of intervention.

Does the Pirani score predict relapse in clubfoot?

PURPOSE

Presented here is a retrospective clinical audit of clubfoot patients to determine the value of the Pirani clubfoot scoring system at initial presentation in the estimation of subsequent relapse.

METHODS

All clubfoot patients treated by the same surgeon from 2002 to 2006 were included. The treatment adhered to the standard protocol, involving weekly stretching and casting until the foot was corrected, followed by Achilles tenotomy and plasters for 3 weeks. Thereafter, the child was placed in a foot abduction splint. The severity of clubfoot was assessed using the Pirani scoring system, consisting of two sub-scores-the midfoot contracture score (MFCS) and the hindfoot contracture score (HFCS). The MFCS and HFCS can each be 0.0-3.0, giving rise to a total Pirani score (TPS) of 0.0-6.0. Any recurrent deformity was classed as a relapse.

RESULTS

Sixty-one clubfoot patients were treated. Five patients were lost to follow-up and six patients were excluded due to the presence of identified syndromes or having had primary treatment elsewhere. A total of 80 clubfeet were included. There were 17 relapses. The average interval between the initiation of foot abduction splint and relapse was 23 months. The median TPS was 3.5 in the no relapse group and 5.0 in the relapse group. The median MFCS was 1.5 in the no relapse group and 2.0 in the relapse group. The median HFCS was 2.0 in the no relapse group and 3.0 in the relapse group. Higher TPS and HFCS were statistically significant when the relapse group was analysed against the no relapse group (P = 0.05 × 10(-4) and 0.02 × 10(-4), respectively).

CONCLUSIONS

Higher Pirani scores were associated with the late relapse group. The TPS and HFCS were shown to be statistically significant predictors of potential relapse. Closer follow-up is advised for patients at risk of relapse.

Familial isolated clubfoot is associated with recurrent chromosome 17q23.1q23.2 microduplications containing TBX4

Clubfoot is a common musculoskeletal birth defect for which few causative genes have been identified. To identify the genes responsible for isolated clubfoot, we screened for genomic copy-number variants with the Affymetrix Genome-wide Human SNP Array 6.0. A recurrent chromosome 17q23.1q23.2 microduplication was identified in 3 of 66 probands with familial isolated clubfoot. The chromosome 17q23.1q23.2 microduplication segregated with autosomal-dominant clubfoot in all three families but with reduced penetrance. Mild short stature was common and one female had developmental hip dysplasia. Subtle skeletal abnormalities consisted of broad and shortened metatarsals and calcanei, small distal tibial epiphyses, and thickened ischia. Several skeletal features were opposite to those described in the reciprocal chromosome 17q23.1q23.2 microdeletion syndrome associated with developmental delay and cardiac and limb abnormalities. Of note, during our study, we also identified a microdeletion at the locus in a sibling pair with isolated clubfoot. The chromosome 17q23.1q23.2 region contains the T-box transcription factor TBX4, a likely target of the bicoid-related transcription factor PITX1 previously implicated in clubfoot etiology. Our result suggests that this chromosome 17q23.1q23.2 microduplication is a relatively common cause of familial isolated clubfoot and provides strong evidence linking clubfoot etiology to abnormal early limb development.

A comparison of percutaneous and mini-open techniques of Achilles tenotomy: an experimental study in rats

PURPOSE

To investigate the effect of Achilles tenotomy performed percutaneously and by mini-open methods on tendon healing and final strength.

MATERIALS AND METHODS

In two groups, each consisting of 14 rats, percutaneous and mini-open techniques in Achilles tenotomy were compared in terms of biomechanical, histological and gross properties.

RESULTS

In the gross evaluation, it was observed that an obvious thickening and adhesion to the subcutaneous tissue of the healing tendon were observed in nearly all rats in which the mini-open technique was performed. In the biomechanical analysis, there was no significant difference between percutaneous and mini-open groups and between operated and intact Achilles tendons in both groups, in terms of tendon strength (P > 0.05). In the histological evaluation, irregularity in the parallel pattern of the collagen fibres, emergence of a non-specific collagenous tissue formation and infiltration of mild mononuclear inflammatory cells were reported. These changes were more marked in the rats in which the percutaneous technique was performed.

CONCLUSION

Mini-open technique for Achilles tenotomy may be considered as an alternative method of treatment to apply the tenotomy technique in a secure way.

CLINICAL RELEVANCE

There are two basic advantages of Achilles tenotomy performed by the mini-incision open technique: (1) a complete tenotomy is guaranteed, as it has to be in the original Ponseti technique, (2) iatrogenic neuro-vascular injury risk is nearly completely avoided due to the subparatenon exploration of the tendon and direct visual observation during the transection. The mini-open technique may only be used in cases in which a vascular compromise is clinically suspected or confirmed by Doppler ultrasonography and/or arteriography. On the other hand, the technique may be performed in all cases routinely by the choice of the surgeon.

Comparison of Ponseti versus surgical treatment for idiopathic clubfoot: a short-term preliminary report

The Ponseti method of treatment for congenital clubfeet has gained widespread clinical acceptance. We have used manipulation, serial casting, and surgery to treat congenital clubfeet for almost 3 decades. Considering the Ponseti method of treatment to replace our traditional treatment method, we conducted a randomized, controlled trial evaluating the short-term outcome of the two treatment protocols. We evaluated foot function and applied a standardized measure of health status for children with orthopaedic problems. Nineteen patients (28 feet) were included in the trial. Nine infants (12 feet) were assigned to the Ponseti treatment group, and 10 (16 feet) were assigned to a group with initial casting and posteromedial release at the age of 6 to 8 months. The minimum followup was 3.3 years (mean, 3.5 years; range 3.3-3.8 years). Outcome measures included the Functional Rating System of Laaveg and Ponseti, the Pediatric Outcomes Data Collection Instrument (PODCI), and standardized radiographic measurements. At last followup the mean Functional Rating score was higher in the Ponseti group. Passive dorsiflexion and passive inversion-eversion were better in the Ponseti group. PODCI scales were comparable and radiographic outcome measures were similar in both groups. This trial has documented a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Evaluation of a disease-specific instrument for idiopathic clubfoot outcome

In 2001, Roye et al. developed a disease-specific instrument (DSI) to measure outcomes of treatment for clubfoot. We assessed this instrument using a cohort of 62 patients, ages 5 through 12 years (mean, 8.6 years), with idiopathic clubfoot who were treated as infants by various methods. Treatment groups were defined by whether the patient received joint-invasive surgery (posterior or posteromedial release surgery) or joint-sparing treatment only (manipulation and casting with or without tendo-Achilles lengthening or anterior tibial tendon transfer). The DSI scales demonstrated internal consistency reliability of 0.74 to 0.85 using Cronbach's alpha. Higher (better) DSI scores were associated with "excellent" general health ratings and better health-related quality of life; lower DSI score were related to special healthcare needs. Patients treated using joint-sparing techniques only (eg, Ponseti technique) had higher DSI scores than those who had received joint-invasive surgery. DSI scores for patients who had received posterior or posterior medial release surgery were very similar to those reported by Roye et al. in New York for a comparable group of patients. Our findings suggest the DSI is sensitive to differences in treatment technique or underlying severity of disease. These data support the use of the Roye DSI as an outcome measure for idiopathic clubfoot in children.

LEVEL OF EVIDENCE

Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Multidisciplinary management of clubfeet using the Ponseti method in a district general hospital setting

PURPOSE

Idiopathic congenital talipes equinovarus (CTEV) is a relatively common complex deformity of the foot that can be successfully managed by the Ponseti method. The purpose of this study was to see if the latter can be effectively administered by non-medical specialists outside a specialist or teaching hospital setting.

METHOD

Retrospective review of 24 children (39 feet) with idiopathic congenital talipes equinovarus managed by a physiotherapist-led service in a district general hospital.

RESULTS

The median Pirani score at presentation was 4.5 (mean 4.2, range 1.5-6). The median Pirani score for feet requiring tenotomy was 6 (4.5-6), whereas feet not requiring tenotomy had a median Pirani score of 2.5 (1.5-5). A total of 18 feet (46%) underwent an Achilles tenotomy. Foot correction was achieved with an average of 3.4 (2-6) cast changes in the non-tenotomy group, and an average of 7.5 (5-13) in the tenotomy group. Successful initial correction of the deformity was achieved in 37 (95%) of the feet studied. One patient (2 feet, 5%) failed local conservative management, requiring tertiary referral. Two children (2 feet) have relapsed, requiring further serial casting. No children required open surgical release. Follow-up was for a mean of 31 months (17-50).

CONCLUSIONS

Early results suggest that a combined consultant/physiotherapist-delivered Ponseti service can be effectively and successfully administered in a district general hospital.

Clubfoot: etiology and treatment

Congenital talipes equinovarus is the commonest congenital anomaly with an incidence of one to two per 1000 live births. Over the centuries it has been treated by various modalities, but the dilemma facing the surgeon has been a strong tendency to relapse. With the use of the Ponseti technique, the number of patients who undergo soft tissue release has decreased. This technique probably represents a panacea for the treatment of this unsolved mystery.

Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nation

Clubfoot is the commonest congenital deformity in babies. More than 100,000 babies are born worldwide each year with congenital clubfoot. Around 80% of the cases occur in developing nations. We treated 154 feet [mean Pirani score (total) 5.57] in 96 children (78 males, 18 females) by the Ponseti method from January 2003 to December 2005. A prospective follow-up for a mean duration of 19.5 months (range 6-32 months) was undertaken. After six months of treatment the Pirani score was reduced to zero for all patients. The results show that corrective surgery, sometimes multiple, can be avoided in most cases which are usually associated with the development of a stiff, painful foot. Low socio-economic status and illiteracy prevailing in developing nations increases the prevalence of neglected clubfoot that is still harder to correct. Integration into various programs and proper use of available resources can decrease neglected clubfoot and improve chances of successful and timely correction of deformity. Bracing constitutes an important part of treatment and proper motivation and education of the parents mitigates the chances of losing correction. The Ponseti method of correcting clubfoot is especially important in developing countries, where operative facilities are not available in the remote areas and well-trained physicians and personnel can manage the cases effectively with cast treatment only.

Validity and responsiveness of the Clubfoot Assessment Protocol (CAP). A methodological study

Background

The Clubfoot Assessment Protocol (CAP) is a multi dimensional instrument designed for longitudinal follow up of the clubfoot deformity during growth. Item reliability has shown to be sufficient. In this article the CAP's validity and responsiveness is studied using the Dimeglio classification scoring as a gold standard.

Methods

Thirty-two children with 45 congenital clubfeet were assessed prospectively and consecutively at ages of new-born, one, two, four months and two years of age.

For convergent/divergent construct validity the Spearman's correlation coefficients were calculated. Discriminate validity was evaluated by studying the scores in bilateral clubfeet. The floor-ceiling effects at baseline (untreated clubfeet) and at two years of age (treated clubfeet) were evaluated. Responsiveness was evaluated by using effect sizes (ES) and by calculating if significant changes (Wilcoxons signed test) had occurred between the different measurement occasions.

Results

High to moderate significant correlation were found between CAP mobility I and morphology and the Dimeglio scores (r_s = 0.77 and 0.44 respectively). Low correlation was found between CAP muscle function, mobility II and motion quality and the Dimeglio scoring system (r_s = 0.20, 0.09 and 0.06 respectively). Of 13 children with bilateral clubfeet, 11 showed different CAP mobility I scores between right and left foot at baseline (untreated) compared with 5 with the Dimeglio score. At the other assessment occasions the CAP mobility I continued to show higher discrimination ability than the Dimeglio. No floor effects and low ceiling effects were found in the untreated clubfeet for both instruments. High ceiling effects were found in the CAP for the treated children and low for the Dimeglio.

Responsiveness was good. ES from untreated to treated ranged from 0.80 to 4.35 for the CAP subgroups and was 4.68 for the Dimeglio. The first four treatment months, the CAP mobility I had generally higher ES compared with the Dimeglio.

Conclusion

The Clubfoot Assessment Protocol shows in this study good validity and responsiveness. The CAP is more responsive when severity ranges between mild – moderate to severe, while the Dimeglio focuses more on the extremes. The ability to discriminate between different mobility status of the right and left foot in bilaterally affected children in this population was higher compared with the Dimeglio score implicating a better sensitivity for the CAP.